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13 t ~'"'1:. AHP Clinical Privileges Update Form Thomas McHugh, CRNA Department of Anesthesiology.rave reviewed the privileges previously granted (copy attached) to me and request the following changes: New Privileges to be Added (please indicate category level and type of experience): Current Privileges not to be renewed: * *Privileges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you will be notified and receive a copy of the report to be filed with the National Practitioner Databank. Date Practitioner's Signature As the Supervising Physician/QI Liaison/Department Chair/Medica! Director/ Service Center Administrator, we have reviewed the above-named AHP's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named AHP's qualifications are appropriate. Since the date of the last -""pointment, we have reviewed applicable information from the following sources of quality and utilization data: ~ Medical Record Review ~ Continuing Education Conferences r;i Physical & Mental Health related to Job Performance Iii Risk Management Events/Quality Management Reports for claims o Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other ' o Annual Evaluation Student Evaluation Annual Review by Dept. Chair or SCA We find as follows: J Acceptable review with recommendation of reappointment with clinical privileges as requested. o Concerns noted on review with corrective action plan in. as requested, but-subjeet"~ a review in months. ~V ' cz- Date Primary Supe si g Physician Sign JI:u/~/1J Date e with recommendation of reappointment with privileges Barbara Castro, M.D. George Rich, M.D. Date Alternate Supervising Physician Signature Alternate Donna Via. Administrator Date Chair/RPC Medical Director Signature (for HSF employees) revised 3/1/2005
14 AHP Clinical Privileges Update Form --rh0/y1ci6 (hl/k;&h Department of - ~IOI() ~have reviewed the privileges previously granted (copy attached) to me and request the following c ~w Privileges to be Added (please indicate category level and type of experience): Current Privileges not to be renewed: * *Privileges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you will be notified and receive a copy of the report to be tiled with the National Practitioner Databank.,A' Date As the Supervising PhysicianlQI Llaison/Department Chair/Medical Directorl Service Center Administrator, we have reviewed the above-named AHP's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named AHP's qualifications are appropriate. Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: ~ ~ Medical Record Review 0" Continuing Education Conferences E1' Physical & Mental Health related to Job Performance 0' Risk Management Events/Quality Management Reports for claims ~ Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA o Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other _ 'We find as follows:. ~AccePtable review with recommendation of reappointment with clinical privileges as requested. o Concerns noted on review with corrective action plan in place with recommendation of reappointment with privileges ~\1.,-'0- LG -s-rt.q bl-or~ Printed me 1Z,vk Date Altern-ate Supervising Physician Signature Date Physician Signature Jttf()v~ Date Chair/RPC Medical Director Signature (for HSF employees) revised 3/1/2005
15 AHP Clinical Privileges Update Form :5hD~.4.~ Department of OP..-fi. (, we reviewed the privileges pre ously granted (copy attached) to me and request the fo ~ew Privileges to be Added (please indicate category level and type of experience): Current Privileges not to be renewed: * *Privileges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you will be notified and receive a copy of the report to be filed with the National Practitioner Databank. Date As the Supervising Physician/QI LiaisonlDepartment Chair/Medical Director/ Service Center Administrator, we have reviewed the above-named AHP's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named AHP's qualifications are appropriate. Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: ~ Medical Record Review." Continuing Education Conferences g-- Physical & Mental Health related to Job Performance [?" Risk Management Events/Quality Management Reports for claims Annual Evaluation 'N U o Student Evaluation o Annual Review by Dept. Chair or SCA o Prescriptive Privileges (8 hours continuing eduacation documentation required every 2 years) Other _ We find as follows: ",/!!;II" Acceptable review with recommendation of reappointment with clinical privileges as requested. o Concerns noted on review with corrective action plan in place with recommendation of reappointment with privileges as requested, but s~ a revie~ in ----r::": -vi "31. ezc? ' ~~~~ _&por", (Ap-fyOj ~ Qate Primary SU~~Sing PhysiCian Signature z,( vi V'!' /~ P/cV I tj i- (J)6{)o/II'JA'L Date Alternatj Supervising Physician Signature Date Alternate Supervising Physician Signature :;F; u-- ~1Ci~ / air/medical Director Signatur (for HSFemployees) /t{~c,p~ revised 1/8/2003
16 Privilege List for: Certified Registered Nurse Anesthetist ~ 15-Apr-05 l-jame: Date: PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLY ASSIGNED TO PRACTICE; EMERGENCY PRIVILEGES SHOULD BE MARKED WHERE YOU ARE THE DESIGNATED PERSON TO COVER AN AREA IN WHICH YOU DO NOT REGULARLY PRACTICE. AREAS IN wnrcn YOU DO NOT REGULARLY PRACTICE SHOULD BE LEFT BLANK. ACCORDING TO THE CATEGORY BELOW, ENTER A. B, OR C IN THE COLUMN NEXT TO THE LISTED PRIVILEGE A The applicant will not undertake patient management except in emergency. B The applicant will manage patients with physician present. C The applicant will manage patients in collaboration and/or consultation with the physician. Medical Medical Medical ~rocedure :ocedure Medical Medical General Injections - Intravenous, Gen'l Anesthesia Preanesthetic Evaluation Preanesthetic Anesthesia Arterial Consent Care Plan line placement Cath Swan Ganz catheter placement Catheter> IV Peripheral - Placement & Mgt Endotracheal Anesthesia Anesthesia Anesthesia Anesthesia Intubation Local Regional - Subcutaneous - IV Blocks Anesthesia - Peripheral Nerve Blocks Anesthesia - Digital Blocks Anesthesia - Caudal Blocks Anesthesia - Epidural Blocks & Catheter Place. Anesthesia - Subarachnoid Blocks & Catheter Place. Anesthesia- Transtracheal Blocks Anesthesia - Topicalization of Airway Anesthesia - General, Inhalation Catheters - Central Venous Pressure Airway Mgt - Mask Ventilation Airway Mgt - Bronchoscopy & Intubation, Fiber Opt Airway Mgt - Laryngeal Mask Airways Airway Mgt - Cornbi-tubes Airway Mgt - Percutaneous Tracheostomy Med Administration Med Administration Med Administration Med Administration Blood Product Post Anesthesia - Topical - Oral - Epidural - Intrathecal Administration Mgt Post Anesthesia Evaluation Authorized to Prescribe Neonatal Pod Adol Adult Geriatric r. c c c. t: c, C- c. f. c, C- r. I C- C. c. c- I P- c. c 0 c.. 8 R c, 'Qt c, Cr c- C c: c, c- C 1', C- c 8 c- C- o G r c- 0 C/ C- c. c. c- :R K e, c. L c. c, c- 1>. 'R c. r: B B c c.! ~ c. e. ~ ('.. v c. 0 \.' r c. ~ C ~ c. c,. C-- c. B.B l!.. c. r c- e- c- g. c. c. c- C C. C- C c. t: e, c. R 'S B B C. c c- c. e e. c c- c. r ~ c. c. i. e, e. c. r/ c. r r c c, c, (" r c c. C- e c c-.r--...: " Page 1 of 2
17 OTHER PRIVILEGES Neonatal Ped Adol Adult Geriatric DATE Signature Name Printed As the Collaborating Physician and Department Chair/Service Center Administrator, we have reviewed the abovenamed practitioner's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named practitioners qualifications are appropriate. DATE Name Printed DATE Name Printed DATE Alternate Supervising Physician Signature Name Printed DATE Name Printed DATE Administrator Name Printed Page 2 of 2
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